Hanley Center Scholarship Fund Form The Hanley Center Scholarship Fund was established by Dr. Jo Linder to provide scholarships to medical students enrolled in an MD or Do program who demonstrate financial need and have a connection to Maine. Since the establishment of the Fund, it has grown with several generous donations made through the MMA/Hanley Center's Annual Fundraising Campaign and other fund-raising efforts, including an annual golf tournament. Applicants must be at least a 2nd year medical student (MD or DO) in good standing. A limited number of scholarships may be granted each year. The application period has now closed.First name(Required)Last name(Required)SSN #Date of birth(Required)Place of birth(Required)Mailing AddressMailing Address(Required)Mailing Address line 2Mailing City(Required)Mailing Address State(Required)Mailing zip code(Required)Legal AddressLegal Address(Required)Legal Address line 2Legal City(Required)Legal zip code(Required)Legal address state(Required)Years at legal address(Required)Contact InformationPhone number(Required)Email address(Required)Family InformationParent's names(Required)Parent's occupations(Required)Parent's addresses(Required)Medical School InformationPre-medical school(Required)Graduation date(Required)GPA(Required)Present medical school(Required)When did/will you enter medical school?(Required)When do you expect to receive your MD or DO degree?(Required)Have you attended any other medical or medically-related schools?(Required) Yes No If yes, when and where?What specialty, if any, have you selected or do you intend to select?Where do you think you might like to practice?(Required)Please tell us something about yourself, to include extracurricular activities.(Required)Application certification: I believe I am eligible for a scholarship from the Hanley Center Scholarship Fund. I certify that all statements made on this application are to the best of my knowledge complete and accurate.(Required) Yes No The Hanley Center reserve the right to request additional information, if needed.Are you applying to the Maine Medical Education Loan Program (through FAME)? (If NO, please continue with Finances Section).(Required) Yes No Finances Please submit a current letter of recommendation and good standing or acceptances to medical school (first year students only) to info@mainephysicians.org with the subject line "Hanley Scholarship Information" and be sure to include your name and contact information in the text of the email and attach required items. Annual Project Income, Available Resources, and College-Related Expenses - dependent or married applicants must include total family income for this application to be considered complete.Part 1: Combined IncomeApplicant's total annual income as reported on income tax returnParent's or partner's/spouse's total annual income as reported on tax return (Put 0 if N/A)Total combined incomePart 2: Available Annual ResourcesEstimate of Total Combined Income (from Part 1) to be applied to annual college-related costs of applicant, if $-0-, please explain.Gifts, grants, scholarships, tuition assistance to be receivedOther available resources including federal/state/other loansTotal resources to be used toward college expensesPart 3: Annual College-Related ExpensesApplicant's tuition feedsApplicant's books and suppliesApplicant's living situation (check one) College room and board Off-campus housing Living at home Related costs associated with living situation selected above:Other household members' annual college-related costs (Put 0 if none)Current annual college loan payments for household membersTotal college-related expenses for applicant and familyAvailable resources less college related expensesFinancial Information Certification: I certify that all financial information on this application is to the best of my knowledge complete and accurate.(Required) Yes No
